Provider Demographics
NPI:1649680109
Name:BARESE, TREVOR H (MA, MPHIL, PHD)
Entity type:Individual
Prefix:DR
First Name:TREVOR
Middle Name:H
Last Name:BARESE
Suffix:
Gender:M
Credentials:MA, MPHIL, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 SUMMER ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-2523
Mailing Address - Country:US
Mailing Address - Phone:203-533-1222
Mailing Address - Fax:
Practice Address - Street 1:89 SUMMER ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-2523
Practice Address - Country:US
Practice Address - Phone:203-533-1222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-05
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA10501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program